Provider Demographics
NPI:1619053915
Name:AMARAL, MANOBALDO MARCOS (PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:MANOBALDO
Middle Name:MARCOS
Last Name:AMARAL
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 KITTREDGE ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-3504
Mailing Address - Country:US
Mailing Address - Phone:617-327-8783
Mailing Address - Fax:
Practice Address - Street 1:390 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02474-6799
Practice Address - Country:US
Practice Address - Phone:857-472-4512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7884103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA463398OtherPROVIDER
MA0501565Medicaid
MA020595820-01OtherPROVIDER
MAW 06139OtherPROVIDER
MA032608609OtherPROVIDER
MA456369000OtherPROVIDER
MA032608609OtherPROVIDER